Total Place is rapidly becoming an issue that public sector managers cannot avoid if they are seen to be addressing the pressures of financial constraint over the next few years. However, the Total Place project is one which raises potential concerns as well as opportunities.
As with any joint working, the parties need clarity as to who is doing what, and who is paying for it. Sitting above that is the governance structures to enable the “partnership” to deliver the benefits for the participants and the local population.
Effective governance needs to ensure that the arrangements are lawful and well managed, which in turn should ensure that decisions are taken effectively and in the light of the relevant information. It is not intended to be a bureaucratic process.
This means clarity about who can take what decisions, and how those decisions should be arrived at. It also requires effective reporting back to the parent authorities and the ability of those bodies to properly hold the partnership to account for delivery of the objectives.
This may involve delegated authority to officers or groups, but care needs to be taken to ensure that authority is in place where decisions are being taken jointly and the lines of accountability are clear.
There are limited powers for cross authority decision making bodies. One of the difficulties in this area is the wide range of joint bodies with differing functions and constitutions which can lead to confusion and overlap between them as well as leading to delay in the decision making process.
The biggest area of concern is the ability of all the participants to manage the financial implications of expenditure by one organisation leading to savings in another. There are mechanisms in place currently which can assist in dealing with this as between different authorities – notably S75 of the NHS Act and Childrens’ trust pooled funds, but both of these have specific rules and limitations.
Grant making powers can also be used to move money around the system where the objects and the recipients match the powers. Current proposals for social impact bonds may assist but there are again limitations or prohibitions on powers of NHS bodies to borrow or invest which will need to be addressed.
In the context of The Innovative Policy Offer it may be easier to identify lead organisations and the governance and management structure, but care will still need to be taken on some of these technical issues:
- confidentiality and information control,
- staff and TUPE,
- Risk and liability
For example NHS bodies carrying out non NHS functions will need to confirm whether or not their actions are covered under the NHSLA schemes – in general they are unlikely to be covered – and make alternative provision. It also remains to be seen whether a retention of employment model will be approved for Total Place schemes where NHS functions move outside NHS providers. These are all issues which have been met in the context of S75 schemes, but the issue become more complex as other players become involved.
The single offer model potentially gives rise to some more complex issues for all participants. The wider the range of functions brought together the greater the risks of individual services being lost in the overarching plan – PCT provider arms have benefited form separate committees to look at their issues even before separation, and the problems of an overarching partnership board with a wide range of public sector functions to oversee may struggle to be more that the local strategic partnership board writ large – can it effectively co-ordinate the differing functions, and give a coherence to the single offer .
In addition to the specific problems for individual service groupings, there will be wider issues to take on board around the relationship between the single offer board and other statutory joint groups – the Children’s Trust Board being an example. It will also have to balance the conflicting accountability routes of the component parts of the offer - how far does NHS direction and local authority members’ accountability to electors sit together in the context of plans for service redesign?
Given the degree of cross party support for the concept and the backing of the Treasury it seems likely that the legal issues in terms of vires will be addressed, although quite in what form remains to be seen. The prizes of more coherent services for users and a more effective use of resources are there to be won, but the structures to manage Total Place will need to be worked on to ensure the gains are achieved and sustainable.
David Owens is a partner at Bevan Brittan LLP